We are not involved in the medical management of the Palestine Action hunger strikers, though we have experience of previous such protests (Families of Palestine Action hunger strikers seek urgent meeting with Lammy, 22 December). The ethical issues are well established: respect for consent, confidentiality, assessment of mental capacity and vigilance for coercion within the doctor-patient relationship.
These prisoners have not faced trial, with some dates set as late as 2027. The damaging effects of prolonged remand on mental health are well known. In this context, voluntary total fasting may be perceived as their only means of protest against detention, so a valid advanced directive, which provides instructions for their medical management when they lose mental capacity, would be essential.
Were we responsible for their care, we would refuse to discharge them from hospital unless the patient wished to return to prison, a stance that emerged after the 1989 anti-apartheid hunger strikes and became known as the “Kalk refusal”. It was so called after one of us, as a physician in a Johannesburg hospital, invoked medical ethics to refuse to release hunger-striking detainees back into state custody. The moral burden on healthcare staff should not be underestimated. Following the death of the IRA hunger striker Bobby Sands in 1981, his doctor later took his own life.
Dr David Nicholl
Consultant neurologist, Hagley, Worcestershire
Dr John Kalk
Retired consultant physician, Oxford
Comments by the prisons minister, Lord Timpson, in relation to the Palestine hunger strikers, that “We are very experienced at dealing with hunger strikes … we have averaged over 200 hunger strike incidents every year and the processes that we have are well-established and they work very well”, are misleading and dangerously complacent (Minister says government not mistreating Palestine Action activists on hunger strike, 18 December). The 200-plus “incidents” he refers to are brief periods of food refusal by individual inmates in prison or immigration removal centres, which, as Dr Ian Miller states in your interview with one of the hunger strikers, Teuta Hoxha, tend to be “quickly abandoned” (‘It feels like being suffocated’: Palestine Action activist in HMP Peterborough vows to continue hunger strike, 20 December).
This hunger strike is very different. It is a coordinated political act by a group of highly motivated and committed activists, and is much more akin to the IRA hunger strike in 1981, when 10 prisoners died. One of them, Martin Hurson, died after 46 days. Of the current hunger strikers, Qesser Zuhrah and Amu Gib are now on day 51, Heba Muraisi day 50, Teuta Hoxha day 45, Kamran Ahmed day 44 and Lewie Chiaramello is on day 17.
Guidance on the medical management of hunger striking in British prisons concentrates on the initial period, leaving prison healthcare staff unclear about appropriate monitoring and thresholds for escalation in more advanced stages. The risks of permanent, severe damage to the health of the hunger strikers, and indeed of them dying, are now extremely high, no matter Lord Timpson’s bland reassurances.
I call on the government to act now, before the grim warning of the hunger strikers’ lawyers is realised, that “young British citizens will die in prison, having never even been convicted of an offence”.
Dr Jonathan Fluxman
Retired GP, London
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